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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5219_Библиотеки_им_академика_М_И_Перельмана.pdf
X
- •Foreword
- •Preface
- •Contents
- •Editors and Contributors
- •About the Editors
- •Contributors
- •1.1 Introduction
- •1.2 Conventional Methods
- •1.2.1 Microscopy
- •1.2.2 Culture
- •1.2.3 Germ Tube Test
- •1.2.5 Carbohydrate Assimilation Test
- •1.2.6 Nitrogen Assimilation Test
- •1.2.7 Carbohydrate Fermentation Test
- •1.2.8 Urease Test
- •1.2.9 Tween 80 Opacity Test
- •1.3 Nonculture-Based Conventional Methods
- •1.3.1 Serological Methods
- •1.3.1.2 ß-d-Glucan
- •1.3.1.3 C. albicans Germ Tube Antibody Assay (CAGTA)
- •1.4 Nucleic Acid-Based Detection
- •1.4.1 Polymerase Chain Reaction (PCR)
- •1.4.3 Peptide Nucleic Acid FISH (PNA-FISH)
- •1.4.4 PCR-Based Innovative Diagnosis
- •1.4.5 FilmArray System
- •1.4.6 Sepsis Flow Chip
- •1.4.7 ePlex System
- •1.4.8 The T2 Candida Assay
- •1.5 Rapid Identification Systems
- •1.5.1 Manual Rapid Identification System
- •1.5.1.1 The API System
- •1.5.1.2 The VITEK System
- •1.5.2 Automatic Rapid Identification System
- •1.5.2.1 MALDI-TOF MS
- •1.5.2.2 The MALDI Sepsityper IVD Kit
- •1.5.2.3 The BioFire FilmArray BCID2 Panel
- •1.5.2.4 The Accelerate Pheno BC Panel
- •1.6 Advanced Diagnostics
- •1.6.2 Biosensor-Based Tests
- •1.6.3 Next-Generation Sequencing (NGS)
- •1.7 Conclusion
- •References
- •2.1 Introduction
- •2.2.1.2 Echinocandins
- •First-Generation Echinocandin
- •Second-Generation Echinocandin
- •2.2.1.3 Other Cell Wall Inhibitors
- •2.2.2.1 Azoles
- •Imidazole
- •Triazole
- •Second-Generation Azole
- •Third-Generation Azole
- •2.2.2.2 Polyenes
- •Other Polyene Under Development
- •2.2.2.3 Allylamines
- •2.2.3 Flucytosine
- •2.3 Conclusion
- •References
- •3.1 Introduction
- •3.2.1 Control Diet
- •3.2.3 Toxification
- •3.2.4 Alternative Treatments
- •3.3.1 Prophylaxis
- •3.3.2 Preemptive Therapies
- •3.3.3 Empirical Therapies
- •3.4 Therapeutic Approach
- •3.4.1 Azoles
- •3.4.2 Echinocandins
- •3.4.3 Polyenes
- •References
- •4.1 Introduction
- •4.3 Eukarya Domain
- •4.4.1 Cryptococcus
- •4.4.2 Aspergillus
- •4.4.3 Mucorales
- •4.4.4 Candida
- •4.5.1 Candida albicans
- •4.5.2 Morphogenesis
- •4.5.3 Pathogenesis
- •4.5.4 Adherence
- •4.5.5 Morphological Switching
- •4.5.6 Invasion
- •4.6 Induced Endocytosis
- •4.7 Active Penetration
- •4.8.2 Biofilm Formation
- •4.8.4.1 Antifungals
- •4.8.4.2 Antifungal Resistance
- •References
- •5.1 Introduction
- •5.2.3.1 Serum
- •5.2.3.2 Low Nitrogen
- •5.2.3.5 Carbon Source
- •5.2.3.6 pH
- •5.2.3.7 N-acetylglucosamine (GlcNAc)
- •5.2.3.8 Quorum Sensing Molecule
- •5.5.5 Surface Colonization Factor1 (SCF1)
- •5.5.6 Other Putative Adhesins
- •5.6.1 Phospholipases
- •5.6.2 Proteinases
- •5.6.3 Hemolysins
- •5.6.4 Lipases
- •5.7 Secreted Cytolytic Peptide: Candidalysin
- •5.5.1 ALS Family
- •5.5.2 HWP Adhesin
- •5.5.3 HYR/IFF Family
- •5.5.4 EPA Family
- •5.9.2 Low Molecular Weight Hsp/Small Heat Shock Proteins
- •5.10.1 Amino Acid/Nitrogen Metabolism
- •5.10.1.1 Amino Acid Sensing Pathway
- •5.12.1.1 Glycolysis
- •5.12.1.2 Gluconeogenesis
- •5.12.1.3 Glyoxylate Cycle
- •5.12.1.4 Fatty Acid Oxidation
- •5.12.3.2 Iron Metabolism
- •5.12.3.3 Candida Iron Transport
- •5.12.3.4 Reductive System
- •5.12.3.5 Siderophore Uptake System
- •5.12.3.6 Haemoglobin-Iron Uptake System
- •5.13.2 Zinc Metabolism
- •References
- •6.1 Introduction
- •6.2 Morphological Switching
- •6.3 Phenotypic Switching
- •6.4 Biofilm Formation
- •6.5 Metabolic Flexibility
- •6.8.1 Hemolysin
- •6.8.2 Phospholipases
- •6.8.3 Proteinase
- •6.8.4 Candidalysin
- •6.12 Conclusion
- •References
- •7.1 Introduction
- •7.2.4 Polymorphism
- •7.2.5.1 Secreted Aspartyl Proteinases
- •7.2.5.2 Phospholipase
- •7.2.6 Calcineurin-Signalling Pathway
- •7.2.7 Ion Homeostasis
- •7.2.7.1 Iron
- •7.2.7.2 Copper
- •7.2.8.1 Capsule
- •7.2.8.2 Melanin
- •7.2.8.3 Heat Shock Proteins
- •7.3 Conclusions
- •References
- •8.1 Introduction
- •8.4.1 ATP-Binding Cassette (ABC) Transporters
- •8.4.2 Major Facilitator Superfamily (MFS) Transporter
- •8.5.1 Biofilm Architecture Among Candida Species
- •References
- •9.1 Introduction
- •References
- •10.1 Introduction
- •10.3 Biofilm
- •10.5 Adherence
- •10.6 Maturation
- •10.8 Dispersion
- •10.11 Animal Models
- •10.18 Photodynamic Therapy
- •References
- •11.1 Introduction
- •11.9 Concluding Remarks
- •References
- •12.1 Introduction
- •12.2 Epidemiology
- •12.3.1 Humoral Response
- •12.3.2 Cellular Immunity
- •12.4 Virulence Factors
- •12.6.1 Fluconazole
- •12.6.2 Polyenes
- •12.6.3 Echinocandins
- •12.7 Drug Resistance
- •12.8 Future Prospects
- •12.9 Conclusions
- •References
- •13.1 Introduction
- •13.4 Translation Research
- •13.4.1 Disease-Oriented Translational Research
- •13.4.2 Lab-Oriented Translational Research
- •13.4.3 Patient-Oriented Translational Research
- •13.5 Conclusion
- •References
- •14.1 Introduction
- •14.2.3 Cutaneous Aspergillosis
- •14.2.4 Ocular Aspergillosis
- •14.2.5 Aspergillus Endocarditis
- •14.2.6 Aspergillus Osteomyelitis
- •14.2.7 Sinus Aspergillosis
- •14.3.2 Histopathology
- •14.3.3 Serological
- •14.3.4 Breath Testing
- •14.3.5 Monoclonal Antibody (mAbs)-Mediated Methods
- •14.4.1 Conventional Therapeutics
- •14.4.1.1 Azoles
- •14.4.1.2 Polyenes
- •14.4.1.3 Echinocandins
- •14.4.1.4 Fluoropyrimidines
- •14.5 Nonconventional Therapeutics
- •14.5.1 Vaccine
- •14.5.2 Monoclonal Antibodies (mAbs)
- •14.5.3 Nanotechnology-Based Therapeutics
- •14.5.4 Immune Therapy
- •14.5.5 Combination Therapy
- •14.8 Conclusion
- •References
- •15: Aspergillus Therapeutics: Future Agents
- •15.1 Introduction
- •15.2.1 Fosmanogepix
- •15.2.2 Ibrexafungerp
- •15.2.3 Olorofim
- •15.2.4 Opelconazole
- •15.2.5 Rezafungin
- •15.2.6 MGCD290
- •15.2.7 Tetrazoles (VT-1129/VT-1161/VT-1598)
- •15.2.8 Nikkomycin Z
- •15.2.9 VL-2397
- •15.2.10 T-2307/ATI-2307
- •15.2.11 Encochleated Amphotericin-B
- •15.2.12 SUBA-Itraconazole
- •15.2.13 Immunotherapy
- •15.2.14 Drug Repurposing
- •References
- •16.1 Introduction
- •16.2 Antifungal Agents
- •16.2.1 Azoles
- •16.2.2 Posaconazole
- •16.2.3 Isavuconazole
- •16.2.4 SUBA—Itraconazole
- •16.2.5 Nanovoriconazole
- •16.2.6 Adverse Effects
- •16.3 Liposomal Amphotericin B (LAMB)
- •16.3.1 Echinocandins
- •16.4 Combination Antifungal Therapy
- •16.5 Therapeutic Drug Monitoring (TDM)
- •16.5.1 Azole-Resistant Aspergillus Spp.
- •16.6 Guideline Recommendations
- •16.10 Conclusion
- •References
- •17.1 Introduction
- •17.3 Potent Antifungal Molecules Under Investigations
- •References
- •19.2 Host–A. fumigatus Interactions
- •19.3.1 Hydrophobicity or Rodlet Layer
- •19.3.2 Conidiation
- •19.3.3 DHN Melanin
- •19.3.5 Siderophores
- •19.3.6 Biofilm Formation
- •19.4 Conclusion
- •References

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G. Gangwar et al.
10.1 Introduction
The global threat posed by the introduction of new microbial diseases and rising
rates of antibiotic resistance persists. The diploid fungus Candida auris, which
belongs to the Metschnikowiaceae family, has seven chromosomes and a genome
that ranges in size from 12.1 to 12.7Mb. The WHO has classied the C. auris infection, which was discovered in Japan in 2009, as urgent. Infections with C. auris are
linked to signicant death rates, which can reach 30–60%. Implanted medical
device, diabetes, recent surgery, and old age are risk factors that are associated with
C. auris infections (Kean and Ramage 2019).
The property of C. auris to withstand multiple drugs makes it a “superbug” that
is posing a risk to human health. Two unique characteristics of C. auris are thermotolerance and salinity tolerance. Candida auris is a member of CTG clade, wherein
CTG codes for serine rather than leucine, just like Candida albicans, Candida tropi-
calis, Candida haemulonii, and Candida lusitaniae. On the basis of genomic data
ve main distinct genetic clades of C. auris are known: the South Asia Clade (I), the
East Asia Clade (II), the South Africa Clade (III), the South America Clade (IV),
and the Iran Clade (V). Due to its ability to mimic the morphology of other closely
related fungi, e.g., C. haemulonii and C. pseudohaemulonii, the identication of this
fungus was critical. Mass spectrometers were used to accurately distinguish it from
other fungi. Recently, a number of diagnostic techniques based on nucleic acid
detection and/or plate assays have improved the accuracy of identication (Du
etal. 2020).
An examination of 350 isolates from India revealed that 90% of the isolates were
insensitive to the antibiotic uconazole, 2% to the micafungin and anidulafungin
(echinocandins), and 8% to amphotericin B (Kean and Ramage 2019). No hospital
disinfectants as such are registered for use specically against C. auris (Cadnum
etal. 2017). In Candida species, the tolerance mechanism to azole antifungal agents
has been described and broadly classied into (a) alterations to the plasma membrane or cell wall that impair the uptake of drugs (azoles); (b) mutation in ERG11
gene; (c) the drug efux pumps of MFS and ABC family (Mishra etal. 2007). The
pathogen exhibits high drug resistance in its biolm form. The Candida auris biolm is robust, according to CDC guidelines. C. auris biolms can endure multiple
harsh environments in addition to being resistant to common disinfectants based on
ammonium salts. Therefore, understanding biolm in the context of infection is
crucial. The molecular underpinnings of this organism’s pathogenicity, the critical
function of biolms, and its resistance to antifungals remain largely unknown,
despite its extraordinary worldwide emergence.
10.2 C. auris Pathogenesis Including Planktonic
andBiofilm Cells
A fungal pathogen’s pathogenicity depends on its capacity to adapt to the stresses
imposed by its host. Several important virulence factors are expressed by C. auris,
including adhesins, the capacity to form biolms, and enzymes like phospholipases,

10 Dissemination ofCandida auris Biolms: AMedical Abrosia
263
proteinases, and secreted aspartic proteases. In an anaerobic environment, C. auris
could not grow. A role for Hog1 stress-activated protein kinase (SAPK) in enhancing stress tolerance has been observed in C. auris. C. auris is also known for its
thermotolerance, which allows it to grow best at 37°C and continue to be viable at
42°C (Bidaud etal. 2018; Forsberg etal. 2019; Jackson etal. 2019). Apart from
temperature, C. auris can withstand hypersaline environments, which can lead to
the formation of pseudohyphae-like morphology, unlike other species of Candida
(Jackson etal. 2019; Kean etal. 2020). Evidence so far suggests that C. auris does
not use morphological switching, which plays a crucial aspect in C. albicans pathogenesis (Larkin etal. 2017; Day etal. 2018). Further, in response to cell cycle arrest
or Hsp90 depletion, which controls antifungal resistance and virulence, Candida
auris undergoes a morphogenetically alteration from yeast to lamentous form.
Cell wall-related genes are impacted by global transcriptional remodelling during
this developmental transition (Vila etal. 2020).
At rst, C. auris was studied for phenotype switching, it did not form hyphae or
pseudohyphae. C. auris can form basic pseudohyphae under high salt concentration
(Sherry etal. 2017). Interestingly, the hyphae coding gene ECE1 and HWP1 are not
present in C. auris (Munoz etal. 2018). In Candida, secreted aspartyl proteinases
(SAPS) virulence factor is present which is responsible for cell-wall formation,
adhesion, biolm, and host tissue degradation. SAPS also inhibit the immune complement system and escape the immune system (de Jong and Hagen 2019; RapalaKozik etal. 2018). In C. albicans SAP4, SAP5, and SAP6 are the most crucial for
virulence (Lee etal. 2009). Hydrolases are the main secreted enzyme in C. auris.
The orthologs of four SAPS have been observed in C. auris genome (Chatterjee
etal. 2015). C. albicans SAPS was observed to be highly active at 25, 37, and 40°C
(Wang etal. 2018) while C. auris SAPS at 42°C, supporting the high-temperature
resistance compared to other species of Candida. Lipase is an another virulence
enzyme that causes biolm formation, kills host cells, and escapes the immune
system (Ghannoum 2000). In experiments involving C. parapsilosis, lipases were
inhibited through knock-down methods. This resulted in the yeast strains being
more readily absorbed by macrophages and less able to evade immune cells than the
control strains (Gacser etal. 2007). Phospholipases secretion is strain dependent
which helps in biolm formation. Cdr1, Snq2, and Yhd3 (ABC transporter protein)
and Rdc3 and Mdr1 (major facilitator protein) are upregulated during mature biolm. C. auris synthesized a lower amount of Als protein (Als1 and Als5) as com-
pared to C. albicans which is required for adhesion (Kean etal. 2018a).
C. auris can form biolm on surfaces for longer time periods and are tough to
eradicate. Biolm helps to protect this organism from antifungal drugs like azoles,
polyenes, and echinocandins. During biolm formation expression some of known
adhesin genes such as IFF4, CSA1, PGA26, HYR3, PGA52, PGA7, and ALS5, etc.,
are induced. In addition, the formation of biolm is accompanied by upregulation of
efux pumps (CDR and MDR), which makes biolm less susceptible to the drug
(Watkins etal. 2022).

264
G. Gangwar et al.
10.3 Biofilm
A group of microbial cells enclosed in an extracellular matrix, known as biolms,
can grow on both biotic as well as abiotic surfaces (Nobile and Johnson 2015).
Generally, microorganisms prefer to grow in the biolm form. Biolm can form on
human surfaces or on an indwelled medical device (Hall-Stoodley etal. 2004).
Initial studies suggested that biolms formed by C. auris are weaker that C. albi-
cans biolms (Oh etal. 2011). C. auris biolms possess relatively high antifungal
drug resistance in comparison to others. In C. auris, the ability of forming biolm
varies from clades to clades. C. auris can form biolms from both aggregated as
well as non-aggregated cell types. Transcriptomics-based studies have unveiled the
crucial role of gene encoding adhesin, transporter pumps, etc., in the development
of biolm. Essentially the C. auris biolms are less explored till date (Du etal.
2020; Kean etal. 2018b).
10.4 Development ofBiofilm andTheir
Molecular Mechanism
Biolm formation involves the role of various differentially expressed transcripts
(Fig.10.1). Basically, biolm formation can be divided into four stages.
10.5 Adherence
The initial adhesion phase of surface colonization is necessary for the start of biolm formation. Several GPI-linked cell wall proteins are highly expressed during
the initial phase of biolm formation, suggesting that these proteins were involved
in the initial adhesion phase. Earlier studies have shown that C. albicans IFF4 and
CSA1 are involved in cell-cell cohesion and adherence to abiotic and mucosal substrates (Table10.1). The function of IFF4in mediating cell-cell contact was postulated by Fox et al.’s transcriptional studies, which revealed that it is a cluster
adhesion transcripts which are activated throughout the process of biolm formation. It is noteworthy that a null mutant of iff4Δ exhibited reduced virulence and
decreased adhesion during the initial stage of biolm formation. Taken as a whole,
both studies demonstrate how important it is for biolm development. Agglutininlike sequence (ALS) protein members are important to Candida albicans adherence, primarily through ALS3. Interestingly, several members of the ALS family are
missing in C. auris. C. auris has two orthologs of ALS1 and ALS5 which are upregulated in mature biolm.
Adhesion plays a crucial role in host surface interaction along with the formation
of multicellular aggregations. The Als proteins are big glycoproteins present on the
outer cell surface of pathogenic Candida that are essential for adhesion to abiotic
and host surfaces, aggregative behaviour, and the formation of biolms. Unlike
C. albicans, which primarily colonizes gastrointestinal and genitourinary tracts,

10 Dissemination ofCandida auris Biolms: AMedical Abrosia
Fig. 10.1 Developmental stages of Candida auris biolm formation
Table 10.1 Biolm-related genes in Candida auris
S.
Function Gene identier
no.
1 Adhesion IFF4, PGA26, PGA52, CSA1, PGA7,
2 Biolm
formation/
maturation
3 Extracellular
matrix
HYR3, ALS5
TRY4, TRY5, ALS4, PGA1, SAP9, SNF2,
BRG1, MP65, AHR1, ASC1
CEK1, TPK2, GAM1, SUR7, ADH2, EPD1,
CBK1, ILS1, RPS4A, RIX7, At2g, ARO1,
STH1, FAS2, PMA1, CPH1, ZPR1, DUS3,
CZF1, SIM1
KRE6, EXG, SAP5, PLB3 Khari etal. (2023),
265
References
Khari etal. (2023),
Kean etal. (2018a),
Zhou etal. (2021)
Khari etal. (2023),
Zhou etal. (2021)
Kean etal. (2018a)
C. auris largely colonizes the skin (Fox etal. 2015; Nobile et al. 2012; Muñoz
etal. 2018).
10.6 Maturation
In this stage, cells keep dividing and begin interacting with one another through a
process called quorum sensing. As a result, a sizable, clumped cell structure is created which is surrounded by an extracellular matrix primarily made of proteins and
polysaccharides (Nobile et al. 2012; Muñoz et al. 2018; Ramage et al. 2002;
Schweizer etal. 2000). The technique quorum sensing (QS) uses the quantity of
microorganisms in a population as a basis for gene expression detection and control.
To form biolms, pathogens utilize the QS mechanism.

266
G. Gangwar et al.
10.7 Quorum Sensing inC. auris
Farnesol is a well-studied quorum-sensing molecule with a potent role in the pathogenesis of C. auris. It can serve as an adjuvant and/or antifungal to inhibit the drug
resistance Candida sp. that may offer a promising substitute for treating Candida
species such as C. auris. Farnesol stimulates reverse morphogenesis and inhibits the
morphogenetic switching of C. albicans. In addition to C. albicans, it also signicantly inhibits non-albicans species and moulds. Treatment with farnesol reduced
biolm-forming capacity in a concentration-dependent way, but it had no effect on
biolm growth after a day. It greatly decreased the growth rate of C. auris but had
no effect on the planktonic C. albicans growth rate (Nagy etal. 2020a). Farnesoltreated C. auris cells affect the expression of efux transporters (Jakab etal. 2021).
Farnesol has no effect on the synthesis of phospholipase in C. auris, in contrast to
C. albicans where it did (Fernandes et al. 2016). Exposure to farnesol caused
C. auris to produce signicantly more reactive species, suggesting no role of farne-
sol in shielding C. auris from oxidative stress. Farnesol thus has distinct effects on
C. auris biolm formation. According to recent research, farnesol inuences the
synthesis of ergosterol by differential regulation of ergosterol biosynthetic genes
(Yu etal. 2012; Nagy etal. 2020b). The inhibitory fungal activity of echinocandins
and uconazole is notably increased by farnesol in a synergistic manner. When
there are enough cells in a system, such as when Saccharomyces sp. and Candida
albicans produce aromatic alcohols, the signal that causes the system to accumulate
and induce biolm formation is one of the key signals for biolm induction (Hogan
2006). Both nitrogen deprivation and neutral alkaline pH are indicators of the onset
of biolm formation. The formation of pseudohyphae in fungi such as Saccharomyces
is indicated by a cascade of aromatic alcohols, also known as fusel alcohol. Low
concentration of nitrogen induces the formation of aromatic alcohols while high
concentration of ammonia limits its formation. Ehrlich’s fusel alcohol formation is
the process through which alcohol dehydrogenases transform aromatic amino acids
that are produced or absorbed into aromatic alcohol. One of the several pathways
that lead to the formation of biolms, the RIM101 pathway, reacts to pH.The two
GPCRs that make up the RIM pathway, RIM9 and RIM21, sense changes in pH in
the surrounding solution and use that information to hyperphosphorylate the protein
RIM8. Essentially, it is a protein that resembles beta-arrestin and triggers the RIM
13 protease. It cleaves and induces transcription activator RIM101. Aro8p and
Aro9p transaminases are produced when the RIM101 transcription factor is activated (Ehrlich 2006; Dai etal. 2021; Parsons etal. 2004; Cornet and Gaillardin
2014; Garnaud etal. 2018; Ghosh etal. 2008). These are necessary to produce the
aromatic alcohols that cause the formation of biolms. Tyrosol functions as a quorum QSM in Candida albicans, while the aromatic alcohols phenylethanol and tryptophol do the same in Saccharomyces (Alem etal. 2006; Chen et al. 2004). The
main glycoprotein on the cell surface of Saccharomyces, Flo11p, acts as a QS path-
way sensor. Additionally, RIM101 controls the expression of several calcium transporters, which in turn regulates the activity of Crz1p via the calcineurin pathway.
This pathway may be in charge of polysaccharide modication proteins, cell wall

10 Dissemination ofCandida auris Biolms: AMedical Abrosia
adhesion, and azole resistance, among other things (Yan etal. 2020; Li etal. 2021a;
Edlind etal. 2002; Miyazaki etal. 2010; Yu etal. 2015; Wang etal. 2011; Xu etal.
2020; Song etal. 2020; Khari etal. 2023).
267
10.8 Dispersion
This is the last step of C. auris biolm lifecycle. This phase involves the bursting out
of above formed enclosed compact structure known to be biolm. In dispersion
phase, matured biolm ruptures to cells to start a new cycle of biolm and free to
cause bloodstream infection in an immunosuppressed person (Kean etal. 2018a).
The factors that trigger dispersion are largely unknown.
10.9 Composition andFunction oftheExtracellular Matrix
Extracellular matrix of biolm is mainly made up of mannan and glucan which play
a pharmacological role in biolm drug resistance by hydrolysing individual polysaccharides (Mitchell etal. 2015). Treatment of biolm with mannosidase and glucanase to disrupt matrix which will increase uconazole susceptibility. These
ndings are consistent with the description of other Candida species (Dominguez
etal. 2019).
10.10 Models inBiofilm Study
A number of models performed that mimic the real in which pathogens produce
biolm have been developed in order to better understand the ner points of biolm.
Vascular catheter model—The development of C. auris biolms is studied in
rats, mice, pigs, and other vertebrates. Mice are less expensive than other animals,
which is an advantage of using them. However, performing surgical procedures is
more difcult due to the diameter of the vessels. Vascular catheter models are among
the most popular tools for evaluating invivo biolm formation. Originally designed
to investigate the pathogenesis linked to Candida albicans biolm, the catheter is
placed in the jugular vein, tunnelled beneath the skin, and protected by a wire casing
(Khari etal. 2023).
Skin models—In hospitals where outbreaks are possible, C. auris is thought to
spread due to its ability to effectively colonize the skin’s surface. Therefore, cultivating C. auris under conditions that most closely resemble the clinical setting can
help gain a better knowledge of C. auris infection (Horton etal. 2020; Johnson etal.
2022; Corzo-León etal. 2022). However, research has shown that C. auris biolm
formation is more prominent in the skin. The management of breakout and the
avoidance of invasive diseases actually depends on our ability to comprehend the
exact mechanism underlying skin colonization and to pinpoint strategies to impede
this process (Khari etal. 2023).

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G. Gangwar et al.
Skin mimics—C. auris can live and multiply on the skin, a special type of media
which mimics skin sweat has been analysed. In synthetic sweat medium, C. auris
was shown to induce C. albicans biolm formation tenfold. Seven days after desiccation, the burden of C. auris was 30 times more compared to C. albicans. After
desiccation, C. auris biolms grew readily, whereas C. albicans was not viable at 14
days (Horton etal. 2020). All things considered, these results demonstrated that
biolms produced by C. auris can withstand desiccation and evaporative sweat drying prominent in the skin. As C. auris grows in a synthetic sweat medium, it produces a multilayer biolm composed entirely of yeast cells. On the other hand,
Candida albicans generated a thin biolm consisting of yeast cells and irregular
hyphae or pseudohyphae. Contrary to what was seen in the RPMI medium, C. auris
biolms were denser compared to C. albicans in the skin mimic medium (Khari
etal. 2023; Abe etal. 2020).
Porcine skin exvivo model—This model involves pig skin which is a close
mimic of human skin in terms of thickness, distribution of cells, and process of
repair (Mitchell etal. 2013; Larkin etal. 2017; Donlan 2001). It is possible to use
skin from biopsy samples taken for a variety of purposes or from animals sacriced
for a variety of reasons. Initially, the skin samples are cleaned hairs removed and the
samples are cut into the proper sizes followed by incubation in semi-solid tissue
culture media. Parafn is applied to the epidermal surface as a barrier. To investigate
biolms, C. auris cells that have grown properly are quantied and then inoculated
onto skin samples that have been prepared (Khari et al. 2023; Corzo-León
etal. 2022).
Human skin exvivo model—The best model for comprehending the formation
of C. auris biolms and its pathogenesis in human skin. The development of a
human skin model with and without an implanted catheter has proven successful in
studying the formation of C. auris biolms. Samples of healthy human skin taken
from abdominal or breast surgeries, for example, can be used for various purposes.
Following a precise cutting and washing process, the tissue skin samples were
mixed with x concentration of C. auris cells at a xed concentration. The growth
of Candida auris was observed under three distinct conditions: (a) unwounded, (b)
wounded, and (c) catheterized. In order to prevent deep penetration, the sample is
repeatedly pricked with the needle to create the wounded samples. A measured
amount of developing C. auris cells are injected into the epidermis of both
unwounded control subjects and wounded test subjects. Subsequently, the skin tissue is permeated with an appropriate-sized catheter onto the epidermis at one edge
in order to analyse the effect of the catheter. Fungal cells are applied via a different
skin edge (Khari etal. 2023; Corzo-León etal. 2022).
10.11 Animal Models
Guinea pig skin model—Pig skin is preferred for studying the pathophysiology of
C. auris due to its striking similarity to human skin. Prednisolone is administered to
animals to cause local immunosuppression in the aficted skin area. A designated,

10 Dissemination ofCandida auris Biolms: AMedical Abrosia
269
cleaned, and hair-free area is chosen and situated behind the guinea pig. To make a
cut without causing bleeding, the skin is gently incised with sterile sandpaper. Over
the chosen area, growing C. auris cells are suspended. On the other hand, no fungal
development was seen when imaging pig skins infected with Candida albicans.
Multiple-layered aggregates were not observed (Khari et al. 2023; Horton
etal. 2020).
Skin colonization and decolonization mouse model—The process of coloniz-
ing the skin involves injecting the mouse’s back skin and pinna. It takes four doses
of the vaccine to guarantee colonization in the mice. Following the establishment of
skin colonization on day 7, test compounds are applied once daily for 7 days to
observe any occurrences of decolonization (Khari etal. 2023; Herrada etal. 2022).
Other models for C. auris pathogenesis—About 30 studies have examined the
pathogenicity of Candida auris using invivo models; the most widely used models
are murine ones. Mammalian models are more costly, require more labour, and take
longer. Using an immune-suppressed mouse model, it was found that invasive
C. auris strains produce more biolm than non-invasive strains (Abe etal. 2020).
Yet, because using invertebrate models of candidiasis raises ethical and nancial
questions, alternative systems are being promoted. Based on different invertebrate
models such as Caenorhabditis elegans, Galleria mellonella, etc., the pathogenesis
of C. auris infection has been extensively studied. It has less ethical issues. Several
routes, including skin surface, injection, and food ingestion, can be used to demonstrate the virulence mechanism of a given pathogen. The study of bloodstream fungal infection is done through haemolymph inoculation. Galleria mellonella is
another well-liked invertebrate model that is smaller, permits multiple inoculations,
has a dened dosage, and grows at 37°C, which is its physiological temperature.
The immune response induced by WT larvae is similar to that of mammals and is
susceptible to fungal infection. Previous studies looked at the in vitro biolmforming, haemolytic, and enzymatic activity of a number of C. auris isolates.
Invertebrate model hosts, G. mellonella and C. elegans, were used to analyse the
virulence properties of these isolates. Notwithstanding the fact that C. auris did not
produce hyphae in the G. mellonella model of candidiasis, these nonaggregating
isolates of the pathogen were discovered to be more virulent than certain isolates of
C. albicans. It was demonstrated that C. auris isolates, both aggregative and nonaggregative, are capable of killing both model organisms. After 120h, at least 47.7%
of the G. mellonella and C. elegans species could be killed by any of the employed
C. auris strains. The G. mellonella and C. elegans models of candidiasis are both
straightforward and appropriate for assessing the pathogenicity of C. auris. G. mel-
lonella, the model host, the microbes can be injected more accurately into host tissues (Khari etal. 2023; Arias etal. 2020).
Gelatin promotes C. auris biolm formation—The pathogenicity and drug tol-
erance of Candida auris are signicantly inuenced by biolm. The heterogenous
substrate-dependent biolm formations are reported. Thereby recently Biswas etal.
devised an invitro culture technique for culturing of C. auris on gelatin-coated
coverslip. Primarily it was based on the understanding that the fungus effectively
colonizes skin and that gelatin resembles the architecture of skin. The most

270
prevalent protein in the body, collagen serves as the foundation for many tissue
formations and is a good substrate for adhesion. Gelatin, a hydrolysed version of
collagen, functions as an adherent mesh and could be a useful dietary source.
Gelatin closely resembles the host’s invivo system and is a less expensive alternative to Thermanox coverslips. The method includes lower handling errors and uses
microscopy for the measurement of biolm. The gelatin-coated coverslip is placed
in a 6-well plate and the biolms are cultivated with RPMI 1640 as media. Biswas
etal. used scanning electron microscopy to image the biolms in order to assess
their architecture and cellular morphology. Compared to Thermanox coverslip surfaces, high-burden biolms were observed on gelatin-coated coverslips. The biolm
was made of yeast cells surrounded by an EPS layer. A very less abundant C. auris
biolm was formed on the Thermanox coverslip (Biswas etal. 2023a).
G. Gangwar et al.
10.12 Role ofRas/cAMP/PKA Signalling Pathway inC. auris
Biofilm Formation
For fungal pathogenesis, biolm formation is an essential part of virulence because
it offers tolerance to antifungal drugs and environmental stresses. Planktonic cell
adhesion to surfaces, maturation, and cell dispersal to form new biolms are the
steps in the biolm formation process. Prior studies have demonstrated that loss of
BCY1 gene results in induced biolm formation while the loss of both TPK1 and
TPK2 genes reduces the formation of biolm. It was discovered that, in comparison
to the wild type, pde1Δ and pde2Δ had greater capacity to form biolms. This
emphasises on the role of Ras/cAMP/PKA signalling on biolm formation in
C. auris. Further expression analysis of cell adhesin genes showed and induced
expression of ALS4in the mutant of BCY1, IRA2, and PDE2. Moreover, the expression of PGA7 and SIT1 was substantially enhanced in the mutant of IRA2, PDE2,
and PDE1PDE2.
A comparative analysis of Pde1Δ and Pde2Δ revealed an antagonistic effect
between the two, with Pde1Δ expressing comparatively less than pde2Δ. This was
due to the consistent increases in ALS4, SIT1, and PGA7 expression levels in
pde2Δ, but only an insignicant increase in pde1Δ. Nevertheless, pde2Δ had higher
expression levels of PGA26 and SAP6, two negative regulators, which may account
for the mutant’s reduced ability to form biolm in comparison to pde1Δ, pde2Δ, and
other mutants. The above results conrmed that the Ras/cAMP/PKA pathway leads
to promote adhesion which is needed for biolm. An exposure of C. auris to PDE2
inhibitor EHNA [erythro-9-(2-hydroxy-3-nonyl)adenine] demonstrated 60%
enhanced expression of PDE2. After receiving EHNA, PDE2 expression rose by
60%, suggesting that the inhibitor was having a compensatory effect. Genes involved
in cell adhesion also showed altered expression levels; in comparison to the untreated
wild-type group, the positive regulator ALS4 increased approximately tenfold, and
PGA7 increased approximately fourfold. On the other hand, PGA26 did not exhibit
a statistically signicant difference, and SAP6, the negative regulator, increased by
about 1.4-fold. SIT1 did not exhibit a signicant difference. The ndings imply that

10 Dissemination ofCandida auris Biolms: AMedical Abrosia
271
C. auris can enhance biolm formation by hyperactivating the Ras/cAMP/PKA
pathway, which in turn can raise the expression levels of several genes linked to
biolm formation. Previous research has shown that deletion of PDEs in C. albicans
results in decreased glycogen accumulation, a decreased ability to survive in nutrient-starved environments, and a diminished ability to cause disease. In A. avus, a
similar nding was also made. Nutrient scarcity in the mammalian host environment impacts a pathogen’s ability to accumulate glycogen as a carbon source and
thus its competitive tness. Furthermore, there was a signicant reduction in the
thermotolerance of the bcy1Δ, pde2Δ, and pde1Δ pde2Δ mutants, which could
potentially lessen their virulence. This could potentially increase the virulence of
C. auris, as the cells within the biolm may be more resilient to the host immune
system. Thus, the less noticeable virulence attenuation in pde2Δ and pde1Δ pde2Δ
mutants may result from these compounding effects caused by activation of the Ras/
cAMP/PKA pathway (Kim etal. 2023).
10.13 Role ofTOR inC. auris Biofilm
Under nitrogen deciency, TOR protein promotes the formation of biolm. RHB1
is sensed through Candida albicans which is an indication of biolm formation.
Mep2 permease and Npr1 kinase circuitry are used for the sensing (Neuhäuser etal.
2011; Rutherford etal. 2019). TorC1 regulates different functions such as cell wall
regulator protein BCR1, hyphal growth gene Efg1, and expression adhesion gene
SFP1. Additionally, Brg1 expression is blocked by recruiting transcriptional repressors such as NRG1 and TUP1 (Chen and Lan 2015). The transcription factor Brg1
is expressed when TOR is inhibited, altering the promoters of hyphal genes
(Flanagan etal. 2017). Additionally, TOR phosphorylates RPS6 to signal ribosome
starvation, which inhibits the anabolic process and initiates the synthesis of stressrelated proteins. This may have an impact on the C. auris stress-related gene translation triggering (Chowdhury and Köhler 2015). C. auris produces less biolm when
TOR is inhibited during the early and intermediate stages of biolm formation
(Biswas et al. 2023b). According to transcriptome studies, adhesion genes are
mostly expressed in the early and intermediate phases of biolm formation (Kean
etal. 2018a). Therefore, C. auris seems to share the same function for Tor in cell
adhesion and biolm formation. For complete understanding, it is necessary to
investigate the associated TOR molecules. Interestingly, based on the protein similarity index between Candida albicans and Candida auris, conserved proteins such
as GPCR Rhb1 (78.02%), Npr1 (61.74%), Vam6 (40.26%), and the central TOR
molecule (77.03%) are found (Biswas etal. 2023a).
In the presence of Tor inhibitors rapamycin and torin2, the biolm formation was
measured. Regardless of when it was added, rapamycin reduced the growth of biolm by 1.4-fold. After 4, 8, and 12h, respectively, torin2 inhibited the formation of
biolm by 1.8-, 1.7-, and 1.2-fold. When cells treated with torin2 were exposed to
biolm formation for 12 h, the degree of inhibition was marginally decreased.
Therefore, even in biolms, inhibition of Tor causes a reduction in cell growth. The
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